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Encephalitis in children

Encephalitis in children

What does the literature say about childhood encephalitis?

Recent studies show that the treatment of encephalitis in children is haphazard and improvements need to the made.  In general children with suspected encephalitis are previously healthy without any neurological conditions. Risk factors are immunosuppressed or travelled overseas. Because it is uncommon and the signs/symptoms are non-specific, initiating treatment is recommended even if there is no significant likelihood that they have the disease. 

The cause of encephalitis can be due to an infectious agent directly or indirectly by other inflammatory pathologies affecting the brain parenchyma. Herpes simplex virus type 1 is the most common cause of sporadic encephalitis.

Symptoms of encephalitis are non-specific, typically children will present with ‘flu-like’ symptoms (headache, nausea, vomiting and altered level of consciousness). Other complaints such as seizures and focal neurological signs are present. There is overlap with acute bacterial meningitis as they can have symptoms of fever, headache and neck stiffness. 

There are specific questions that must be asked by physician

  • Vaccination history
  • Travel history
  • History of a rash in child or contacts
  • Presence of cold sore or stomatitis may be caused by HSV 1

The absence of meningism should not be used to rule out encephalitis. 

Physicians should look for other symptoms such as raised blood pressure, papilloedema, abnormal pupil responses, abnormal flexion or extension to painful stimulus, altered breathing.

The failure to control the seizures is a risk factor for raised intracranial pressure, increased metabolic activity, acidosis and vasodilation

Early diagnosis is very important in order to treat the clinical syndrome and seek aetiology of the disease. Routinely it is advised to perform FBC, urea and electrolytes, liver function test, capillary glucose, blood gas, lactate, urinalysis and CSF.  

The best test to accurately determine encephalitis is autopsy or brain biopsy which is not practical. Surrogate markers include inflammatory cells in the spinal fluid or changes in brain imaging. CSF may be negative in the early stages of the disease. Neuroimaging is key in order to provide direct evidence of brain involvement from an infectious process or provide alternative diagnosis (space occupying legion, abscesses, vascular events etc). MRI is more sensitive. 

CT may misdiagnose HSV infection in the early stages of the condition whilst MRI will be able to detect other conditions (Kirkham 2012). 

Treatment is started with broad spectrum antimicrobials and antiviral medication while awaiting results of diagnostic studies.  Studies show that if therapy is commenced late, poor prognosis will ensue. So there should be a low threshold for starting acyclovir in suspected cases of encephalitis. 

However, there are also guidelines that suggests starting Aciclovir should not be commenced in children with known epilepsy with an increase in seizure and known febrile illness or acute head injury. 

Prognosis is generally poor for children with long-term neurological outcomes even despite appropriate therapy. Up to 67% of children will have long-term morbidity. 

In sum there are many unanswered questions about the ideal management and treatment of encephalitis due to lack of reporting, unknown aetiology in the majority of cases and few data on long-term outcomes.  The triage and appropriate treatment of children presenting with seizures, reduced level of consciousness or behavioural problems is complex and a controversial issue. 

References:

Thomson C, Knew R, Riodan A, Kelly D, Pollard AJ. Encephalitis in children. Archives of Disease in Childhood, 28 February 2012, Vol.97(2), p.150

Kirkham F. Guidelines for the management of encephalitis in children. Developmental Medicine & Child Neurology 2013, 55: 107–110

Fear of dentists

Fear of dentists

Are you afraid of dentists? Don’t worry, you are not the only one. Worldwide, the phobia of dentists also known as dental phobia is very common. In the list of phobias, dentistry is often in the first position. Dental phobia appears to be the most common phobia in the world, followed by height and spider phobia.

Where does this fear come from?  And what can you do about it?

Usually, dental phobia is related to past negative experiences.  You might have not yet found that dentist who is capable of helping you to get over your fear. It takes time, lots of patience and love for your profession to help patients like you overcome their fear. One important thing that will help you, is try to find a dentist that will listen well to you and that is very empathic. Ask friends, colleagues and family members if they have someone in mind, some empathic dentist that they would recommend you to attend to.
Avoid making an appointment directly for a treatment, but instead, make a first appointment just to get to know that dentist ,just like going on a first date. Also let this dentist do only a check-up of your teeth on the first appointment. No drilling, no clean up, nothing except a check-up, talk and explain the treatment.

If the first impression you get of your dentist is a good one, and you feel calm while being with her/him, then you can make a new appointment for the needed treatment. 

What are the three things I do to help you overcome your dental phobia?

 

  1. Determine if my patient is extremely afraid of dental treatment or not. If my patient is afraid of dental treatment, our conversations and the length of our appointments will be different than by patients who aren’t.
  2. Focus on explaining procedures slowly, and in a careful way. My goal at this time is to make sure you understand how special you are and how your treatment will be performed. I do this in a calm and effective manner.
  3. Give you time and let you realise that it is a process . Getting over or improving a phobia is not an easy task for most patients, so together, we have to keep this in mind and have lots of patience.

Appointments with your dentist in case of dental phobia should be a bit longer. This time is necessary in order to explain procedures carefully and not rush in any treatment. I want to let all my patient take their time.

If you’d like to discuss your dental fears, and how to overcome them, or if you have any other questions related to your oral health, feel free to book an online appointment with me and discuss it. 

Remember your dental phobia can be overcome.